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Waste Tire Su., y & Inspection Report nspection Report Number <br /> `ysa State of California Survey Form - Page 1 I 1 - 1140735 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- t� Inspection Type (Fill one) <br /> Site Suffix: t7f 0 Ll 7 O ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> �tW1c,-��" IVA w Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 7-ca--l- <br /> - - - — <br /> !� Inspected By Inspector <br /> 2 <br /> Physical Address 3 <br /> Lf B q S S. Pati rpm Vj cn <br /> Inspection Date C) A © $ ( b <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> I 4 6 0 PM 2 '13 d O PM <br /> - -- - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude i Q Hauler Q Indoor <br /> O I <br /> Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility " <br /> V' EM <br /> A HAULING ANANDMANIFEST REQUIRENTS � �� �� '` <br /> �. � �� f <br /> 41 <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires t <br /> Q ! Q PRC§42953-Contracts with Registered Waste Tire Haulers. ' <br /> Q Q PRC§42956- Registration/Decal in Vehicle <br /> Q Q 114 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB - <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q 1 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § ...z; <br /> Comments <br /> ►'� C n�(kc.Q�sew �--�Yy�.¢�z3_oy— 4'(ti i S C.6kj_< - <br /> Inspection Form <br /> CommentIncluded: Q, <br /> �,Business ep's Signature Ph a umberInspectatu Phone Number <br /> INSTRUCTIONS ON BACK Ct�t`rec r !�,l,�, ecat ' ? � ALX r> M P � � � 62081 <br /> - � <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop :LE <br />